Provider Demographics
NPI:1659511350
Name:MOORE, SUSAN P (PT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:P
Last Name:MOORE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2725 NE 25TH PL
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33305-1705
Mailing Address - Country:US
Mailing Address - Phone:954-561-6962
Mailing Address - Fax:
Practice Address - Street 1:4747 N OCEAN DR
Practice Address - Street 2:STE 261
Practice Address - City:LAUDERDALE BY THE SEA
Practice Address - State:FL
Practice Address - Zip Code:33308-2947
Practice Address - Country:US
Practice Address - Phone:954-785-4776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-20
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT4201225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT4201OtherSTATE LICENSE NUMBER